Inspection on 17/08/06 for Cloverdale Care Home

This inspection was carried out on 17th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cloverdale Care Home 20/10/08

Cloverdale Care Home 21/11/07

Cloverdale Care Home 03/03/06

Cloverdale Care Home 21/10/05

Cloverdale Care Home 20/01/05

Cloverdale Care Home 13/07/04

Cloverdale Care Home 06/02/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cloverdale Care Home 68 Butt Lane Laceby Grimsby North East Lincs DN37 7AH Lead Inspector Beverly Hill Key Unannounced Inspection 17th August 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cloverdale Care Home Address 68 Butt Lane Laceby Grimsby North East Lincs DN37 7AH 01472 877000 01472 877111 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Dryband One Ltd Lynette Amy Green Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: Cloverdale Care Home is registered for the care of forty service users with residential care needs. The home is situated on the outskirts of Laceby village, in North East Lincolnshire, about six miles south of the town of Grimsby. The home is purpose built, all service user accommodation being provided at ground level. All forty bedrooms are single and thirty-nine have en-suite facilities. The home has four bathrooms with toilets and an assisted shower room. There are also four single toilets throughout the home strategically placed for ease of access. The home has two lounges and a dining room with a seating area at one end for service users who wish to smoke. Cloverdale Care Home is set in its own grounds and enjoys a pleasant aspect of open countryside. A paved walkway surrounds the home and there are ample parking spaces to the front of the building. The home is well maintained, clean and has a homely feel. According to information received from the home on 29.06.06 their weekly fees are £329. Items not included in the fee are toiletries, hairdressing, escorts for non-emergency appointments and chiropody. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day. Throughout the day the inspector spoke to seven service users to gain a picture of what life was like for people who lived at Cloverdale. The inspector also had discussions with the manager, five care staff and two catering staff. The inspector looked at assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. The inspector also checked with service users to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. The inspector also observed the way staff spoke to service users and supported them, and checked out with them their understanding of how to maintain privacy, dignity and choice. Prior to the visit to the home the inspector had sent out a selection of surveys to service users, some family members, a selection of staff members and professional visitors to the home. Those returned were checked and comments used throughout the report. Out of twelve returned from service users ten stated they ‘always’ or ‘usually’ received the care and support they needed whilst the remaining two stated this was ‘sometimes’. Comments from service users in this part of the survey were that staff members have changed quite often and it takes a while for younger carers to get up to speed with understanding service users needs. Nine were positive about staff listening to them, two felt this was ‘sometimes’ and cited, ‘staff spread too thinly’ as the reason and one felt they were not listened to. The majority of service users were positive about staff availability, access to medical support, meals and whether the home provided them with enough information initially to enable them to make a choice about the home. Out of six replies from relatives, three stated they felt there was insufficient staff all the time which resulted in some delays in meeting needs but one commented on the hard work of the care staff, ‘the care is superb’ and five had ticked the box to indicate they were satisfied with the overall care. One had left this blank. Staff members indicated they enjoyed their jobs and felt well supported. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager must make sure that the home receives copies of assessments and care plans completed by care management so they have full information about the service users needs before they are admitted. The manager also needs to write to service users or their relatives following the assessment stating that the home is able to meet the needs that had been identified when they visited the person. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 7 Some service users were able to do some things independently but these were not always written into the care plan and if the staff members don’t know about them they may do the tasks for the person rather than encouraging or promoting their independence. There were also some changes in peoples’ abilities, which were mentioned in the monthly recordings in the care plans. These changes need to be written in the actual care plan where care staff members were more likely to read them. It had been identified that two people had a risk of falls but risk management plans had not been written and another person had bedrails in place but on two occasions these had not been effective so the risk assessment needed to be reviewed. Some bedrails did not have protectors on and another bed did not have the rail fitted properly. Although this was sorted out during the inspection it was important to monitor bedrails and have good risk assessments and plans to reduce risk to protect service users health and welfare. Some activities were provided for people but views on whether these were sufficient and met everyone’s needs varied. It was important for the home to provide a range of activities for people. The way the home recruits staff must be improved as this was mentioned at the last inspection. One new staff file examined did not have two references. Good recruitment practices were essential to ensure the right staff members were employed and service users were protected. Supervision had improved but there were still some gaps to address. There had been some staff shortages but it was hoped the recent recruitment of new staff would solve this problem. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users had assessments of need completed prior to admission but the home did not always obtain copies of assessments completed by care management. The home offered visits and trial stays so people could assess the services provided by the home. EVIDENCE: The home evidenced that service users were only admitted after the manager carried out an assessment of need. However one of the care files examined was a service user admitted for respite. Care management funded the placement and had assessed them but the home had not obtained a copy of their assessment or care plan. This was important to enable the home to make a decision based on full information as to whether the persons’ needs could be met. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 10 The home had a form to use when the assessment had been completed to formally notify service users or their representative that they were able to meet the assessed needs. However three of the four care files examined were recent admissions to the home and the form was on file but had not been completed and given to the service user. The manager confirmed that service users and their relatives tended to be informed verbally. The home had appropriate moving and handling equipment to meet the needs of the current service users and staff members had developed good working relationships with professionals who visited the home. Staff described how they supported someone during admission to settle in, introducing them to other service users, showing them around and unpacking belongings. The manager and staff confirmed that the home offered day care and short respite stays and this enabled people to see what the home was like. The home had two service users currently using the respite service. The manager confirmed that the first six weeks of admission was a trial period and after this time a decision was made as to permanent residency. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To ensure service users assessed needs were met and maintained, the home needed a consistent approach to care planning and risk assessment. Staff supported service users in a way that promoted privacy and dignity. EVIDENCE: The care plans formulated were pre-printed sheets for each identified need and then individualised for each service user. A separate care plan was used for service users admitted for respite, which was a shortened version of the main care plan. Although some care plans contained a range of needs with tasks for staff to complete to meet the needs, the tasks were very generalised. For example, one stated ‘assistance to wash and shave’, yet the assessment stated the service user was usually able to wash their upper body and shave themselves. The care plan needs to reflect the staff support needed to enable the service user to continue with their independence in maintaining these particular skills. Also some evaluation records indicated changes had occurred, for example in the amount of support a service user needed with eating their Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 12 meals. This had not been changed in the care plan. Staff would read care plans but would not necessarily read through all the monthly evaluations so changes in needs must be reflected in care plans. The care files contained a lot of information to enable a very individualised care plan. One care plan examined reflected the close relationship the person had with their family and two others made clear the choices regarding religious observance the service users had made. The care files indicated that service users accessed health care professionals when required and those spoken to felt their health and personal care needs were met in a way that respected privacy and dignity. Each bedroom had an indicator light on the outside that when pressed inside informed people not to enter as personal care tasks were taking place. There was evidence of individual risk assessments in place for some activities but this was not consistently the case in all files examined. For example two of the four care files indicated that service users were at risk of falls but risk assessments with how this was to be managed had not been completed. A risk assessment for bed rails for one person had only partially been completed but the bed rails were in place. Records showed that one service user had been assessed for bed rails but these were not effective on two occasions so an update in the risk assessment was required. Medication was managed well. It was stored, recorded and administered appropriately. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided nutritional meals, generally flexible routines and enabled service users to make choices about aspects of their lives. A range of activities to suit all needs and preferences would enhance the quality of life for people. EVIDENCE: The information regarding the provision of activities and service user satisfaction was mixed. Four of the twelve surveys received stated that there were always sufficient activities, however other comments were that there were very few arranged and one person stated, ‘there are no outings arranged by the home as they led us to believe there would be’. There was some evidence of bingo, occasional visiting entertainers, manicures, one to one chats and organised events such as football parties during the world cup, sing-alongs and a cream tea. From the survey results it would seem that the home have not got it quite right for everyone. Some individual logs were maintained but not for all service users. The manager stated that a community occupational therapist had visited Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 14 the home and gave advice about activities but there was no evidence to support that any advice had been put into practice. The inspector witnessed open visiting and service users confirmed their relatives were always made welcome. In discussions they also stated they were satisfied with the food provided and they could make choices about aspects of their lives such as when to get up and retire, activities, whether to have a male or female carer and meals. Documentation and a check of the premises showed that some people chose to have their own telephone and personalise their bedrooms. The inspector observed staff respecting peoples’ choice of what to have for their meals and in discussions staff members described how they tried to ensure service users made choices with the clothes they wore, when they wanted to bathe and where they wanted to sit in the home; their own room or communal areas. There were certainly signs of well being in the home especially at lunchtime when it was observed that staff and some service users enjoyed banter with each other. Menus looked varied, and catered for special diets such as diabetics, vegetarian, low fat and fortified. The meal sampled was well cooked and presented. The cook indicated that service users were offered choices if they chose to have something different from the main meal on offer. They confirmed that people could make suggestions about the menu and cited the recent addition of rabbit to the menu as a result of a suggestion by a service user. Service users confirmed staff checked out with them daily what they wanted. One service user stated, ‘ the food is brilliant and there are always two to three vegetables at each meal’. One person stated, ‘if you don’t like it they’ll get you something else’. One survey from a service user stated, ‘generally the food is good but I buy extra because I prefer better quality provisions’. Another survey highlighted that the evening meal was served at 4pm, which they thought was very early and so chose to purchase extra items to eat later in the evening. The manager confirmed that supper was available. The timing of the evening meal needs to be checked out with people and steps taken to respond to and meet individual needs. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of training in adult protection for some staff and insufficient recruitment documentation could place service users at risk. EVIDENCE: The home had a complaints procedure and forms to complete should anyone make a formal complaint. Staff members were aware of the complaints process and the procedure was displayed in the home. Two out of six relatives’ surveys indicated they were unaware of the complaints process but they had never had to complain. Service users spoken to stated they would complain to the manager, mentioning her by name or the team leaders. The manager stated the home had not received any complaints since the last inspection. Not all staff had received training in the protection of vulnerable adults from abuse and this was confirmed in staff surveys, training records and discussions during the inspection. However senior care staff members spoken to during the inspection were clear about the action to be taken should they suspect abuse had taken place or it was reported to them. The manager was clear about their responsibilities in referring any allegations to social services. Deficiencies in recruitment practices, for example not consistently obtaining two references for staff could place service users at risk. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 16 Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a clean environment with accessible communal space and service users were able to personalise their bedrooms. EVIDENCE: Generally the home was clean, fresh smelling and tidy and the domestic staff obviously tried hard to maintain standards. Out of twelve service user surveys nine felt the home was clean and fresh, ‘always’ or ‘usually’. Two stated ‘sometimes’ and one form did not have this section completed. One survey did state, ‘It’s not as clean and fresh smelling as when I was first here’ and ‘my room is not hovered very regularly’. Service users spoken to comment, ‘it’s always clean and tidy’, ‘I’m very happy with the cleanliness of my room’ and ‘my room is cleaned every day’. Those bedrooms examined were clean and tidy apart from one bedroom, which had an odour that needed addressing. The Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 18 home used melamine teapots, which preserved the heat, however they were badly stained, looked unsightly and were in need of cleaning. Bedrooms were personalised to varying degrees and had lockable facilities and privacy locks to the doors when requested. People spoken to stated they were able to bring in pictures, ornaments and even items of furniture. The home had two lounges, one of which was only used by a small number of service users. One relative survey suggested smaller groupings of seating in the larger lounge, however, the manager confirmed this had been tried but service users had requested this be returned to its original state. The well maintained garden area was accessed via the large lounge and the courtyard via both the small lounge and dining room. The manager confirmed that they and maintenance personnel checked the home on a regular basis and two-monthly meetings had been commenced to highlight any environmental issues and to record any actions that were required with timescales. The maintenance person completed their own weekly audits and had a request book for staff to complete. Redecoration of bedrooms and the home in general was completed when required or when bedrooms were vacated. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally competent and willing staff members supported service users but there had been gaps in staff availability, which could affect the care received. The current system of staff recruitment lacked robustness necessary for the protection of service users. EVIDENCE: Staffing rotas were examined and it was indicated that four staff were on duty during the day and three staff at night. On the day of the inspection there were thirty service users but this fluctuated as the home supported people who were admitted for regular respite care and sometimes day care. Although the manager had identified which service users had high, medium and low dependency needs in order to determine how many staffing hours were required, this was not calculated using any identifiable tool but was more an estimate by the manager. It was important that the amount of hours provided met those required and this needed to be calculated using an appropriate tool. Three out of six relatives felt that there was not always sufficient staff members on duty and some service users also felt staff were rushed and ‘spread too thinly’, which affected the time spent with people and the quality of some care tasks especially in the mornings. One visitor stated that their Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 20 relatives’ fingernails could be checked and cleaned more often. However there were very positive comments about staff attitude and the inspector observed genuine warmth between staff and service users and in discussion staff members appeared very committed to their work. One relative survey stated, ‘I visit my mother regularly and don’t think she would get better care anywhere’, whilst another stated, ‘low levels of staffing are occurring more and more frequently but the care is superb’. The staff confirmed that the manager had recently recruited new care staff, which should help to alleviate recent problems. Documentation was examined regarding the recruitment practices of the home. Out of the three files examined one did not have any references in place. These had been requested but had not been received and the staff member had been employed without them. The manager must ensure that robust recruitment takes place or this could place service users at risk. The manager had identified training needs for the year including updates and had completed individual logs that indicated when training had been completed, who the facilitator was and when the renewal date was due. Records examined showed that the home was progressing well with staff training. Not all staff had received mandatory training, although it was recognised that this was mainly new staff and was an ongoing process. Records highlighted that eight care staff had completed NVQ Level 2 and 3. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements had been made in the overall management of the home. However areas such as staff supervision and proactive health and safety monitoring need to be developed further for the health and welfare of service users. EVIDENCE: The manager had completed the Registered Manager Award and is a moving and handling trainer for the company. The manager was very focussed on meeting service users needs. Progress was noted in some of the management systems, for example the majority of staff had received one supervision session and communication systems between staff had improved. Service users finances continued to be managed well and the annual quality assurance Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 22 programme was well under way. Improving systems was an ongoing process for the manager as some staff surveys did indicate that they had not received regular supervision. This applied to mainly night care workers. Team Leaders spoken to had started to supervise care staff so this will improve the whole staff supervision system. Although communication systems had improved and staff members were highlighting important issues that affected service users, these were not always acted on quickly. Staff commented the home was a nice place to work, moral was improving as more staff had recently been recruited, the team were motivated and got on well with each other and had a good rapport with service users and relatives. A variety of staff meetings were held and service user meetings had just restarted in June. The home did obtain the views of service users, relatives, staff and visiting professionals via their quality assurance questionnaires and action plans were formulated to address any shortfalls. The company produced an annual service review, which included the results. Other sections of quality monitoring were completed with regular audits and checks. Service users personal allowance was well managed and individual logs and receipts were maintained. Those service users who were able to manage their own finances had lockable facilities in their bedrooms. General health and safety was maintained via adherence to policies and procedures, staff training and the maintenance of equipment. However some risk assessments needed closer monitoring and some bedrails required protectors. The latter was addressed on the day of the inspection. One bed had a bedrail at only one side. This was unsafe and was removed. The manager confirmed the service user no longer needed it, however the risk assessment should have been reviewed sooner and action taken straight away. Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 Requirement The registered person must ensure that two written references are consistently obtained prior to employment. (Previous timescale of 31/03/06 not met) The registered person must ensure that all care staff members are on track to receive at least six formal supervision sessions per year. (Previous timescale of 30/04/06 not met) The process has started. Timescale for action 30/09/06 2. OP36 18(2) 31/12/06 3. OP3 14 4. OP7 15 The registered person must 30/09/06 ensure that assessments and care plans completed by care management are obtained by the home and the service users or their representatives receive formal confirmation that, having regard for the assessment, their needs can be met in the home. The registered person must 31/10/06 ensure that care plans have clear tasks for staff in how to maintain service users independent skills and changes highlighted in DS0000002780.V295626.R01.S.doc Version 5.2 Page 25 Cloverdale Care Home 5. OP8 13 6. OP12 13 7. OP15 12 and 16 8. OP18 13 9. OP26 23 9. OP27 18 10. OP38 13 evaluations are followed through to the care plans. The registered person must ensure that risk assessments are completed for the two service users at risk of falls, risk assessments for bedrails are updated when needs change or the plan becomes ineffective. The registered person must ensure that the activities provided suit the range of needs experienced by the service users. The registered manager must seek service users views on the timing of the evening meal and supper provisions and ensure that there is less than a twelvehour gap between the provision of supper and breakfast the next morning. Individual needs to be accommodated as far as practicable. The registered person must ensure that all staff including ancillary staff receive training in the protection of vulnerable adults from abuse. The registered person must ensure that the odour in one of the bedrooms is investigated and eliminated and the melamine teapots cleaned or replaced. The registered person must ensure the correct staffing hours are provided to meet service users needs. It is recognised that newly recruited staff, about to start induction, may resolve the issue. The registered manager must be proactive in monitoring health and safety issues within the home such as risk assessments, bed rails and protectors. 30/09/06 31/10/06 30/09/06 31/12/06 30/09/06 30/09/06 30/09/06 Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations The registered manager should document and use the advice from occupational therapists on assessment techniques of older people regarding social activities and the types of activities that would be appropriate for them. The registered manager should calculate dependency levels of service users and hence the required staffing hours by using an appropriate tool. The registered person should ensure that staff receive three paid training days per year. The home should continue to work towards 50 of staff trained to NVQ Level 2. 2. 3. 4. OP27 OP30 OP28 Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cloverdale Care Home DS0000002780.V295626.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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